Form 433-B (OIC) (Rev. 3-2018)

1 Form 433-B (OIC) (March 2018) Department of the Treasury internal revenue Service Collection Information Statement for Businesses Complete this form if your business is a Corporation Partnership Limited Liability Company (LLC) classified as a corporation Other LLC Note: If your business is a sole proprietorship or was a disregarded single member LLC taxed as a sole proprietor (filing Schedule C, D, E, F, etc.) prior to 2009, do not use this form. Instead, complete Form 433-A (OIC) Collection Information Statement for Wage Earners and Self-Employed Individuals. This form should only be used with the Form 656, Offer in Compromise. Include attachments if additional space is needed to respond completely to any question. Section 1 Business InformationBusiness Name Employer Identification Number Business Physical Address (street, city, state, zip code) Primary Phone ( ) -Secondary Phone ( ) -Business website address County of Business Location Description of Business and DBA or "Trade Name" Business Mailing Address (if different from above or Post Office Box number) Fax Number( ) -Federal Contractor YesNoTotal Number of Employees Frequency of Tax Deposits Average Gross Monthly Payroll $Does the business outsource its payroll processing and tax return preparation for a fee?

2 YesNoIf yes, list provider name and address in box below (Street, City, State, ZIP Code) Provide information about all partners, officers, LLC members, major shareholders (foreign and domestic), etc., associated with the business. Include attachments if additional space is needed. Last Name First Name Title Percent of Ownership and Annual Salary Social Security Number --Home Address (Street, City, State, ZIP Code) Primary Phone ( ) -Secondary Phone ( ) -Last Name First Name Title Percent of Ownership and Annual Salary Social Security Number --Home Address (Street, City, State, ZIP Code) Primary Phone ( ) -Secondary Phone ( ) -Last Name First Name Title Percent of Ownership and Annual Salary Social Security Number --Home Address (Street, City, State, ZIP Code) Primary Phone ( ) -Secondary Phone ( ) -Catalog Number 55897B Form 433-B (OIC) (Rev. 3-2018) Page 2 of 6 Section 2 Business Asset Information Gather the most current statement from banks, lenders on loans, mortgages (including second mortgages), monthly payments, loan balances, and accountant's depreciation schedules, if applicable.

3 Also, include make/model/year/mileage of vehicles and current value of business assets. To estimate the current value, you may consult resources like Kelley Blue Book ( ), NADA ( ), local real estate postings of properties similar to yours, and any other websites or publications that show what the business assets would be worth if you were to sell them. Asset value is subject to adjustment by IRS. Enter the total amount available for each of the following (if additional space is needed, please include attachments). Round to the nearest dollar. Do not enter a negative number. If any line item is a negative number, enter "0".Cash and Investments (domestic and foreign) CashChecking SavingsMoney Market Account/CDOnline AccountStored Value CardVirtual CurrencyBank Name Account Number (1a) $ CashChecking SavingsMoney Market Account/CDOnline AccountStored Value CardBank Name Account Number (1b) $ CashChecking SavingsMoney Market Account/CDOnline AccountStored Value CardBank Name Account Number (1c) $ Total bank accounts from attachment (1d) $ Add lines (1a) through (1d) =(1) $ Investment Account: StocksBondsOtherName of Financial Institution Account Number Current Market Value $ X.

4 8 = $ Minus Loan Balance $ = (2a) $ Investment Account: StocksBondsOtherName of Financial Institution Account Number Current Market Value $ X .8 = $ Minus Loan Balance $ = (2b) $ Total investment accounts from attachment. [current market value minus loan balance(s)] (2c) $ Add lines (2a) through (2c) = (2) $ Notes Receivable Do you have notes receivable? YesNoIf yes, attach current listing which includes name, age, and amount of note(s) receivable. Accounts Receivable Do you have accounts receivable, including e-payment, factoring companies, and any bartering or online auction accounts? YesNoIf yes, you may be asked to provide a list of name, age, and amount of the account(s) receivable. Catalog Number 55897B Form 433-B (OIC) (Rev. 3-2018) Page 3 of 6 Section 2 (Continued) Business Asset Information If the business owns more properties, vehicles, or equipment than shown in this form, please list on a separate attachment.

5 Real Estate (Buildings, Lots, Commercial Property, etc.) Property Address (Street Address, City, State, ZIP Code) Property Description Date Purchased Name of CreditorDate of Final PaymentCounty and Country Current Market Value $ X .8 = $ Minus Loan Balance (mortgages, etc.) $ Total Value of Real Estate =(3a) $ Property Address (Street Address, City, State, ZIP Code) Property Description Date Purchased Name of CreditorDate of Final PaymentCounty and Country Current Market Value $ X .8 = $ Minus Loan Balance (mortgages, etc.) $ Total Value of Real Estate =(3b) $ Total value of property(s) listed from attachment [current market value X .8 minus any loan balance(s)] (3c) $ Add lines (3a) through (3c) = (3) $ Business Vehicles (cars, boats, motorcycles, trailers, etc.). If additional space is needed, list on an attachment. Vehicle Make & Model Year Date Purchased Mileage or Use HoursLeaseLoanName of CreditorDate of Final Payment Monthly Lease/Loan Amount $Current Market Value $ X.

6 8 = $ Minus Loan Balance $ Total value of vehicle (if the vehicle is leased, enter 0 as the total value) = (4a) $ Vehicle Make & Model Year Date Purchased Mileage or Use HoursLeaseLoanName of CreditorDate of Final Payment Monthly Lease/Loan Amount $Current Market Value $ X .8 = $ Minus Loan Balance $ Total value of vehicle (if the vehicle is leased, enter 0 as the total value) = (4b) $ Vehicle Make & Model Year Date Purchased Mileage or Use HoursLeaseLoanName of CreditorDate of Final Payment Monthly Lease/Loan Amount $Current Market Value $ X .8 = $ Minus Loan Balance $ Total value of vehicle (if the vehicle is leased, enter 0 as the total value) = (4c) $ Total value of vehicles listed from attachment [current market value X .8 minus any loan balance(s)] (4d) $ Add lines (4a) through (4d) = (4) $ Catalog Number 55897B Form 433-B (OIC) (Rev. 3-2018) Page 4 of 6 Section 2 (Continued) Business Asset Information Other Business Equipment [If you have more than one piece of equipment, please list on a separate attachment and put the total of all equipment in box (5b)]Type of equipmentCurrent Market Value $ X.

7 8 = $ Minus Loan Balance $ Total value of equipment (if leased or used in the production of income enter 0 as the total value) = (5a) $ Total value of equipment listed from attachment [current market value X .8 minus any loan balance(s)] (5b) $ Total value of all business equipment Add lines (5a) and (5b) = (5) $ Do not include amount on the lines with a letter beside the number. Round to the nearest dollar. Do not enter a negative number. If any line item is a negative number, enter "0" on that line. Add lines (1) through (5) and enter the amount in Box A = Box A Available Equity in Assets $Section 3 Business Income Information Enter the average gross monthly income of your business. To determine your gross monthly income use the most recent 6-12 months documentation of commissions, invoices, gross receipts from sales/ services , etc.; most recent 6-12 months earnings statements, etc., from every other source of income (such as rental income, interest and dividends, or subsidies); or you may use the most recent 6-12 months Profit and Loss (P&L) to provide the information of income and expenses.

8 Note: If you provide a current profit and loss statement for the information below, enter the total gross monthly income in Box B below. Do not complete lines (6) - (10). Entire household income should also include income that is considered as not taxable and may not be included on your tax return. Gross receipts (6) $ Gross rental income (7) $ Interest income (8) $ Dividends (9) $ Other income (Specify on attachment) (10) $ Round to the nearest dollar. Do not enter a negative number. If any line item is a negative number, enter "0" on that line. Add lines (6) through (10) and enter the amount in Box B =Box B Total Business Income $Section 4 Business Expense Information Enter the average gross monthly expenses for your business using your most recent 6-12 months statements, bills, receipts, or other documents showing monthly recurring expenses. Note: If you provide a current profit and loss statement for the information below, enter the total monthly expenses in Box C below.

9 Do not complete lines (11) - (20). Materials purchased ( , items directly related to the production of a product or service) (11) $ Inventory purchased ( , goods bought for resale) (12) $ Gross wages and salaries (13) $ Rent (14) $ Supplies (items used to conduct business and used up within one year, , books, office supplies, professional equipment, etc.) (15) $ Utilities/telephones (16) $ Vehicle costs (gas, oil, repairs, maintenance) (17) $ Insurance (other than life) (18) $ Current taxes ( , real estate, state, and local income tax, excise franchise, occupational, personal property, sales and employer's portion of employment taxes, etc.) (19) $ Other expenses ( , secured debt payments. Specify on attachment. Do not include credit card payments) (20) $ Round to the nearest dollar. Do not enter a negative number. If any line item is a negative number, enter "0" on that line. Add lines (11) through (20) and enter the amount in Box C = Round to the nearest dollar.

10 Do not enter a negative number. If any line item is a negative number, enter "0" on that line. Subtract Box C from Box B and enter the amount in Box D =Box C Total Business Expenses $Box D Remaining Monthly Income $Catalog Number 55897B Form 433-B (OIC) (Rev. 3-2018) Page 5 of 6 Section 5 Calculate Your Minimum Offer Amount The next steps calculate your minimum offer amount. The amount of time you take to pay your offer in full will affect your minimum offer amount. Paying over a shorter period of time will result in a smaller minimum offer amount. If you will pay your offer in 5 or fewer payments within 5 months or less, multiply "Remaining Monthly Income" (Box D) by 12 to get "Future Remaining Income." Do not enter a number less than zero. Note: The multipliers below (12 and 24) and the calculated offer amount do not apply if IRS determines you have the ability to pay your tax debt in full within the legal period to collect.